Supportive care and euthanasia--an ethical dilemma?
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Public policy on the development and use of genetically modified organisms (GMOs) has mainly been concerned with defining proper strategies of risk management. However, surveys and focus group interviews show that although lay people are concerned with risks, they also emphasize that genetic modification is ethically questionable in itself. Many people feel that this technology "tampers with nature" in an unacceptable manner. This is often identified as an objection to the crossing of species borders in producing transgenic organisms. Most scientists reject these opinions as based on insufficient knowledge about biotechnology, the concept of species, and nature in general. Some recent projects of genetic modification aim to accommodate the above mentioned concerns by altering the expression of endogenous genes rather than introducing genes from other species. There can be good scientific reasons for this approach, in addition to strategic reasons related to greater public acceptability. But are there also moral reasons for choosing intragenic rather than transgenic modification? I suggest three interrelated moral reasons for giving priority to intragenic modification. First, we should respect the opinions of lay people even when their view is contrary to scientific consensus; they express an alternative world-view, not scientific ignorance. Second, staying within species borders by strengthening endogenous traits reduces the risks and scientific uncertainty. Third, we should show respect for nature as a complex system of laws and interconnections that we cannot fully control. The main moral reason for intragenic modification, in our view, is the need to respect the "otherness" of nature.
Prenatal screening for illegal drugs poses very complex ethical problems for the nurse-midwife who must make the decision whether to screen for illegal drugs and whether to report positive results to state child abuse investigators. We argue that the results of prenatal screening for illegal drug use should not be used for determination of child abuse and that the nurse-midwife should not be required to report the results of these screens for illegal drugs to state child protection agencies. It is far from clear that required reporting offers any benefit to the fetus or future child, and there are serious ramifications of reporting for the fetus, the pregnant woman, and the nurse-midwifery profession. However, we do argue that prenatal screening for both illegal and legal drug use should be encouraged and should be done as early as possible in the pregnancy. Prenatal screening for drugs should only be used by the nurse-midwife as a diagnostic procedure wherein standard informed consent and confidentiality restraints are maintained.
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Two alternatives to physician-assisted suicide are ethically supported and legally permitted by American law. They are proper pain management and the forgoing of life-sustaining treatment. Correct understanding of pain management in the context of the dying patient shows that it is always medically possible, and, assuming that the proper decision-maker agrees, it is always legally permitted to eliminate physical pain in an imminently dying patient. It is also ethically right and legal to withhold or withdrew life-sustaining treatment in many cases. These alternatives significantly reduce, though they do not eliminate, the perceived need for suicide and euthanasia. Neither euthanasia nor physician-assisted suicide should be made legal, although they may be morally right in cases in which adequate pain control is unavailable. Reasons for this conclusion are discussed.
In medical ethics, principles have an important but frequently overextended role. The need for exact answers and moral formulae sometimes leads to the misuse of principles, such that they usurp the central place of persons and become ends in themselves. The Baby Jane Doe case is discussed as a prominent instance of both the proper uses and abuses of principles. A more fitting role for principles is described and illustrated, stressing the use of principles as tools of moral discernment and the time-laden character of moral judgments.
The title, 'justice across the generations', is reminiscent of expressions such as 'hands across the seas'. The latter is, of course, impossible in reality, but it symbolizes friendship between persons in far-flung lands. Is 'justice across the generations', likewise, no more than a hopeful metaphor, or is there, or at least should there be, some concrete reality to it? If so, what is, or should be, the substance of that reality? This text consists of some free association reflections, principally in the context of health care and mainly in the form of questions, on the concepts proclaimed in the title, namely, justice, across and generations, and what relevance these might have for our present and future societies.
Although the Netherlands, Germany, and the United States are alike in having aging populations who die primarily of deteriorative diseases, they face end-of-life dilemmas quite differently. In the United States, withholding and withdrawing of treatment are the only legally recognized means for easing dying. In Holland, voluntary active euthanasia is also practiced; in (West) Germany, assisted suicide is a legal option, usually outside the medical setting. This paper examines objections to these three practices, and observes the differences in the background cultures. Rather than reliance on any of the three, it argues that physician-assisted suicide in terminal illness is the practice most compatible with the United States' special characteristics.
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